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File: Corporate Pdf 155118 | 508 Cpha13 Pharmacy And Therapeutics Committee
policy and procedure department reference number cc phar 13 pharmacy operations effective date 02 10 policy name pharmacy therapeutics committee reviewed revised date 08 10 retired date n a 07 ...

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                                                                             POLICY AND PROCEDURE 
                          DEPARTMENT:                                                                REFERENCE NUMBER:  CC.PHAR.13 
                          Pharmacy Operations 
                          EFFECTIVE DATE: 02/10                                                      POLICY NAME:  Pharmacy & Therapeutics 
                                                                                                     Committee 
                          REVIEWED/REVISED DATE:  08/10,                                             RETIRED DATE: N/A 
                          07/11, 02/12, 02/13, 02/14, 08/14, 08/15, 
                          08/16, 11/16, 02/17, 02/18, 02/19, 02/20, 
                          02/21, 05/21, 08/21 
                          PRODUCT TYPE: Medicaid                                                     PAGE: Page 1 of 6 
                         
                        SCOPE: Centene Health Plan Pharmacy Department, Centene Corporate Pharmacy Solutions, 
                        Centene Corporate Pharmacy and Therapeutics Committee, and Envolve Pharmacy Solutions. 
                         
                                                PHARMACY & THERAPEUTICS COMMITTEE CHARTER 
                         
                              1.  PURPOSE.  The purpose of the Centene Pharmacy & Therapeutics (P&T) Committee is 
                                    to  review  and  make  decisions  for  changes  to  the  drugs  listed  for  coverage,  the  edits 
                                    related  to  controls  or  limitations  of  drug  coverage,  and  the  policies  and  procedures 
                                    governing provision of drug coverage under the Medicaid Preferred Drug List (PDL) to 
                                    promote access to safe, effective and quality drug therapy. Centene and its subsidiaries do 
                                    not discriminate on the basis of race, color, national origin, sex, age or disability, nor 
                                    exclude from participation in, deny the benefits of, or otherwise subject to discrimination 
                                    under any applicable Company health program or activity. The Centene P&T Committee: 
                         
                                    a.  Objectively appraises, evaluates, and selects drugs for coverage on the Medicaid 
                                          PDL. 
                                    b.  Meets quarterly, and if necessary more frequently, to review and update the PDL to 
                                          consider adding newly approved drugs and recommending  changes to existing drug 
                                          coverage in consideration of changes in FDA approved labeling, safety concerns, or 
                                          current market conditions.   
                                    c.  Reviews and approves Drug Utilization Review (DUR) initiatives delegated to the 
                                          Clinical Pharmacy Advisory Committee (CPAC) and Envolve Pharmacy Solutions 
                                          that are sent to health plans for provider or member intervention. 
                                    d.  Reviews, updates, and approves policies and procedures governing provision of the 
                                          Medicaid pharmacy benefits.   
                                    e.  Reviews, updates, and approves criteria guidelines for the use of restricted access 
                                          drugs and non-PDL covered drug therapy. 
                                    f.    Reviews newly FDA approved drug products within 90 days, and reach a coverage 
                                          decision for each newly FDA approved drug within 180 days of  market availability. 
                                    g.  Reviews and evaluates the clinical appropriateness protocols and procedures for 
                                          formulary exceptions and other utilization management activities such as prior 
                                          authorizations, step therapies, quantity limits, generic substitutions, drug utilization, 
                                          drug compliance and related activities that impact consumer access to drugs. The P&T 
                                          Committee set protocols and procedures which insure that drug utilization management 
                                          decisions are evidence-based clinical decisions.  
                         
                               
                                           
                                                                             POLICY AND PROCEDURE 
                          DEPARTMENT:                                                                REFERENCE NUMBER:  CC.PHAR.13 
                          Pharmacy Operations 
                          EFFECTIVE DATE: 02/10                                                      POLICY NAME:  Pharmacy & Therapeutics 
                                                                                                     Committee 
                          REVIEWED/REVISED DATE:  08/10,                                             RETIRED DATE: N/A 
                          07/11, 02/12, 02/13, 02/14, 08/14, 08/15, 
                          08/16, 11/16, 02/17, 02/18, 02/19, 02/20, 
                          02/21, 05/21, 08/21 
                          PRODUCT TYPE: Medicaid                                                     PAGE: Page 2 of 6 
                         
                              2.  MEMBERSHIP & ORGANIZATION.  The Centene P&T Committee is chaired by the 
                                    Centene Vice President (VP) of Medical Affairs, or the Centene Chief Medical Officer or 
                                    his/her designee.  The Secretary of the Committee is Centene’s Director of Medical 
                                    Affairs Pharmacy Operations or his/her designee. Voting members of the Committee 
                                    include appropriately credentialed community-based practitioners and pharmacists 
                                    representing various clinical specialties that adequately represent the needs of Centene 
                                    health plan members. The Committee includes at least one practicing physician and one 
                                    practicing pharmacist who are experts regarding the care of elderly or disabled 
                                    individuals. Outside specialty consultants, independent and free of conflict with respect to 
                                    Centene health plans and pharmaceutical manufactures, may be recruited as deemed 
                                    necessary, to provide input related to their areas of expertise and to provide advice on 
                                    specialty practice standards. All members will be required to participate in the annual 
                                    conflict of interest training along with signed documentation. All members have an 
                                    ongoing responsibility to disclose conflicts of interest if they arise. A quorum is required 
                                    to transact business and make decisions, which is at minimum 50% of Centene P&T 
                                    Committee members, three (3) of whom must be community based practitioners.  
                                     
                                    All members shall serve a two-year term. Every two years members will be contacted to 
                                    confirm their willingness to continue participation in the P&T Committee. Once a member 
                                    confirms willingness to continue, the member will fill a subsequent two year appointment 
                                    unless resignation or less than 50% attendance applies. Employees of pharmaceutical 
                                    manufacturers and other product sponsor representatives may not serve as members of the 
                                    P&T Committee or attend meetings.  
                                     
                              3.  ATTENDANCE AND PARTICIPATION.  It is the responsibility of all members to 
                                    ensure optimal discussion of agenda items. Membership of the P&T Committee reflects a 
                                    multi-disciplinary approach to drug evaluation.  
                                     
                                    Attendance of greater than 50% of P&T Committee meetings in a rolling 12 months is 
                                    required to maintain the rights of a voting member. 
                                     
                              4.  RESPONSIBILITIES.   The Centene P&T Committee carries out its mission and 
                                    performs its duties by applying the following principles: 
                                     
                                    a.  Clinical decisions are based on the strength of scientific evidence and standards of 
                                          practice that include, but are not limited to, the following: 
                                           i.   Assessing peer reviewed medical literature, randomized clinical trials, and 
                                                outcomes research data. 
                                                                             POLICY AND PROCEDURE 
                          DEPARTMENT:                                                                REFERENCE NUMBER:  CC.PHAR.13 
                          Pharmacy Operations 
                          EFFECTIVE DATE: 02/10                                                      POLICY NAME:  Pharmacy & Therapeutics 
                                                                                                     Committee 
                          REVIEWED/REVISED DATE:  08/10,                                             RETIRED DATE: N/A 
                          07/11, 02/12, 02/13, 02/14, 08/14, 08/15, 
                          08/16, 11/16, 02/17, 02/18, 02/19, 02/20, 
                          02/21, 05/21, 08/21 
                          PRODUCT TYPE: Medicaid                                                     PAGE: Page 3 of 6 
                         
                                          ii.   Employing well established clinical practice guidelines developed by means of an 
                                                evidence-based process and make use of other sources of appropriate information. 
                                         iii.   Comparing the safety, efficacy, the frequency of side effects and potential drug 
                                                interactions among alternative drug products. 
                                         iv.  Assessing the likely impact of a drug product on patient compliance when 
                                                compared to alternative products. 
                                          v.  Basing PDL coverage decisions on a thorough evaluation of the benefits, risks, 
                                                and potential outcomes for patients. 
                                         vi.  Reviewing and monitoring medication utilization trends and comparing data to 
                                                recognize and established professional practice standards or protocols to facilitate 
                                                the development or revision of coverage criteria, to assess appropriate use, to 
                                                make recommendations for changes in PDL positioning, and to provide feedback 
                                                to prescribers. 
                                        vii.  Review, at least annually, the prior authorization and medical necessity criteria 
                                                guidelines for drug coverage to ensure they reflect current market conditions and 
                                                standards of care. 
                                    b.  The Centene P&T Committee works in coordination with the Strategy Development 
                                          Committee (SDC) who make PDL decisions through financial analyses that are 
                                          consistent with Centene P&T clinical decisions and state-specific regulatory 
                                          requirements. The SDC manages drug cost using a multi-disciplinary standardized 
                                          approach to identify, develop, and implement long- and short-term strategies in 
                                          support of health plan financial and other business objectives. Data and analytics 
                                          optimize decision-making.  
                                    c.  Ad hoc meetings, if necessary, may be in the form of an in-person meeting, via phone 
                                          or an online meeting with online vote. Decisions rendered through ad hoc meetings 
                                          are considered effective as of the date of the final vote and will be brought to 
                                          quarterly meeting for review and notation in meeting minutes. This section does not 
                                          absolve the CPTC from all requirements provided for under the Membership and 
                                          Organization section. 
                                    d.  Administrative considerations include, but are not limited to, the following: 
                                           i.   Notifying Centene health plans regarding any suggestions for additions, deletions, 
                                                or changes to the PDL, clinical guidelines, or utilization edits.  
                                          ii.   Notifying Centene health plans, via committee meeting minutes, of the 
                                                proceedings and decisions made by the Committee. 
                                         iii.   Notifying Centene health plans of the Committee’s meeting schedule on an 
                                                annual basis. 
                                                 
                                                                             POLICY AND PROCEDURE 
                          DEPARTMENT:                                                                REFERENCE NUMBER:  CC.PHAR.13 
                          Pharmacy Operations 
                          EFFECTIVE DATE: 02/10                                                      POLICY NAME:  Pharmacy & Therapeutics 
                                                                                                     Committee 
                          REVIEWED/REVISED DATE:  08/10,                                             RETIRED DATE: N/A 
                          07/11, 02/12, 02/13, 02/14, 08/14, 08/15, 
                          08/16, 11/16, 02/17, 02/18, 02/19, 02/20, 
                          02/21, 05/21, 08/21 
                          PRODUCT TYPE: Medicaid                                                     PAGE: Page 4 of 6 
                         
                              5.  DELEGATED FUNCTIONS.  The Centene P&T Committee delegates the creation of 
                                    oncology product(s) clinical criteria to an external vendor for those health plans that have 
                                    signed a delegation agreement, unless there are state mandated criteria. Such agreements 
                                    are subject to vendor oversight and annual review of the delegate’s clinical policies.  
                               
                               
                              6.  REVIEW OF CHARTER.  The Centene P&T Committee reviews this charter annually 
                                    from the date of original approval or revision date, whichever is more current. 
                         
                        REFERENCES: N/A 
                        ATTACHMENTS:  
                         
                        Attachment A: Iowa Addendum 
                         CC.PHAR.13_Attach
                        m                          m
                           ent_Iowa Addendu _062021.docx
                                                   
                         Attachment B: South Carolina Addendum 
                         CC.PHAR.13_Attach
                        m
                           ent B_SC Addendum_6.21.21.docx
                                                   
                         D
                           EFINITIONS: N/A 
                          
                                                                                   R
                                                                                      EVISION LOG 
                         R
                           EVISION                                                                                                                        DATE 
                         A
                           ddition of language requiring annual review of PA and MN criteria                                                              08/10 
                        by Corporate and Health Plan Pharmacy and Therapeutics 
                        Committees.   
                         A
                           ddition of quorum requirements.                                                                                                08/10 
                         Clerical changes.                                                                                                                07/11 
                         No changes.                                                                                                                      02/12 
                         Clerical grammatical changes.                                                                                                    02/13 
                         No changes deemed necessary.                                                                                                     02/14 
                         No changes deemed necessary.                                                                                                     08/14 
                         Changed VP of Pharmacy to VP of Pharmacy Solutions Group.                                                                        08/15 
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...Policy and procedure department reference number cc phar pharmacy operations effective date name therapeutics committee reviewed revised retired n a product type medicaid page of scope centene health plan corporate solutions envolve charter purpose the p t is to review make decisions for changes drugs listed coverage edits related controls or limitations drug policies procedures governing provision under preferred list pdl promote access safe quality therapy its subsidiaries do not discriminate on basis race color national origin sex age disability nor exclude from participation in deny benefits otherwise subject discrimination any applicable company program activity objectively appraises evaluates selects b meets quarterly if necessary more frequently update consider adding newly approved recommending existing consideration fda labeling safety concerns current market conditions c reviews approves utilization dur initiatives delegated clinical advisory cpac that are sent plans provider...

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